Get Connecticut Health And Welfare Fee Assessment

Filling out the Connecticut Health And Welfare Fee Assessment is an essential task for various reporting entities within the state. This guide offers clear instructions on how to successfully complete the form online, ensuring compliance with the relevant regulations.

Follow the steps to complete the assessment form online.

1. Press the ‘Get Form’ button to obtain the form and open it for editing.
2. Indicate your filing category by selecting one of the options: Insurer, Exempt Insurer, or Third-Party Administrator (TPA). Remember, each entity type must file a separate form.
3. In the ‘Reporting Entity’ section, provide the name, address, contact person, phone number, and email address of your organization. Ensure all details are accurate to facilitate communication.
4. Report the total number of insured or enrolled lives in Connecticut as of May 1, 2012, in the designated field. This number should reflect all eligible lives as specified under section 38a-469, such as Basic Hospital Expense Coverage and Major Medical Expense Coverage. If applicable, write 'NONE' if there are no insured lives.
5. In the ‘Certification’ section, fill in the date, title of the officer, and the name of the reporting entity. The responsible individual must sign and date this section, confirming the accuracy of the information provided.
6. After completing all sections of the form, review your entries for accuracy and completeness. Once satisfied, proceed to save the changes.
7. Finalize the process by downloading, printing, or sharing the completed form as required.

Complete your Connecticut Health And Welfare Fee Assessment form online today to ensure timely filing!